ADA PARATRANSIT SERVICE
Eligibility Information Sheet
What is the ADA (Americans with Disabilities Act)?
The American with Disabilities Act (ADA) is a civil rights law. The intent of the ADA is to remove
barriers that have prevented people with disabilities from fully participating in life. Under the ADA,
Go West buses are to be the primary means of public transportation for everyone, including people
with disabilities.
The Americans with Disabilities Act (ADA) requires that complimentary paratransit (curb-to-curb)
service be available to persons who, because of a disability, are unable to use the regular bus system.
McDonough County Public Transportation (MCPT) either operates or provides funding to operate this
service in Macomb.
Service Boundaries
The service boundaries for complimentary paratransit services provided by McDonough County Public
Transportation in conjunction with Go West Transit are the municipal boundaries of the city of
Macomb.
Eligibility
Eligibility for paratransit service is based upon a person’s functional inability to use regular Go West
bus service. Three categories of persons who are eligible for paratransit are established by the ADA.
Category 1
Any person who is unable, because of a disability, to independently board, ride, and/or disembark
from a lift equipped bus. This includes persons who are unable to “navigate” Go West’s system
without the assistance of another person.
Category 2
Any person with a disability who is able to use a lift or ramp equipped bus, but for whom any desired
trip cannot be made because the fixed route he/she wants to ride is not operated by a lift equipped bus.
Currently 100% of Go West’s regular buses are ramp equipped. Persons in this category may not be eligible for
paratransit service.
Category 3
Any person with a disability who has a specific impairment-related condition that prevents him or her
from traveling to or from a boarding or disembarking location.
Conditional Eligibility
Some people with disabilities may be able to use the regular Go West bus service under certain
conditions, but not under others. Therefore, eligibility for paratransit for some people will be
determined on a trip-by-trip basis.
A
Temporary Eligibility
A person with a temporary disability will be eligible for paratransit service if the disability results in
his/her functional inability to use the Go West bus system as described in the three eligibility
categories. Temporary eligibility may be granted up to the amount of time recommended by a medical
professional.
Visitors
If you are eligible for paratransit services by another agency or have a disability and plan on visiting
our area, you may be given “presumptive” eligibility to use paratransit services for up to 21 days.
Visitors should complete only part A of this application and return it to Disability Support Services.
In-Person Evaluation
It may be necessary for some paratransit applicants to participate in an in-person evaluation to
determine eligibility for paratransit services. Notification will be given if this will be required.
Mobile Assistive Devices
Mobile assistive devices included in the complimentary paratransit service may not exceed 30” (width)
and 48” (length) and may not exceed 600 pounds when occupied.
Right to Appeal
Persons who are denied eligibility for paratransit services have the right to appeal the decision.
A request for appeal must be filed in writing within 60 days of the denial of the application. The
Appeals Committee will review your appeal. Appeal decisions are made within 30 days of their
delivery.
Renewals
Paratransit eligibility may be granted for up to four years. New applications must be submitted to
renew service. Renewal applications should be submitted at least 30 days prior to the expiration date
of your eligibility period. To request an application, please call 309-298-3553, or visit our website at
www.gowest.wiu.edu.
Submit completed applications to DSS. You will be notified in writing whether or not you are eligible
within 21 days of DSS receiving your application; however, incomplete applications may take longer to
process. Please include a color photo of yourself no smaller than 1.5 inches x 2 inches. Photos cannot be
returned. You may also visit the DSS headquarters to have your photo taken. If you need further
assistance with your photo, please call 298-2512.
Travel Training
Go West offers free one-on-one training to teach people with disabilities how to ride the regular city
buses. Call Go West for Travel Training information at 309-298-3553.
To request this application in an alternative format (Braille), please call DSS at 298-2512.
B
PART-A
FOR THE APPLICANT TO COMPLETE
•
If you believe that you have a disability that prevents you from using the Go West bus, please
complete this application and return it to DSS. Your disability must prevent you from using the
Go West bus system. Please read the ADA Paratransit Information Sheet carefully for further
clarification.
•
An in-person evaluation of your inability to use the Go West bus may be necessary. You may be
found eligible for paratransit curb-to-curb service for all of your trips, for some of your trips, or
capable of using the Go West bus.
•
It is important that all parts of this application be completed. If not, it will be returned to you for
completion. All information will be kept confidential.
PLEASE PRINT
Name, First: _______________________ Last: _______________________ Initial: ________
Title:
❑ Mr.
❑ Mrs.
❑ Ms.
❑ Miss
❑ Other: ________
Are you a ? (Circle one)
New Applicant
Renewal Applicant
Date of Birth (month/date/year):
________ / ________ / ________
Address: ___________________________ City: _______________________ Zip: ________
Phone (day): __________________ (evening) __________________ TDD: _______________
In case of emergency, notify:
Name: ________________________________ Phone: _______________________
Do you reside with:
❑ Family/Friend
❑ By Yourself
❑ Supported Living
❑ Group Home
❑ Nursing Home
❑ Assisted Living
Please indicate the type of alternative format you require for future mailings:
❑ None
❑ Cassette
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❑ Large Print
PART A – FOR THE APPLICANT TO COMPLETE
Disability Information
A. Please choose the best category that describes how your disability affects your ability to
ride the city bus. (See information sheet for further clarification.)
❑ I am always able to ride Go West buses but with some difficulty.
❑ I am unable to ride Go West buses without the assistance of someone else.
❑ I am unable to get to and from the bus stop.
❑ I am unable to board Go West buses without the use of a ramp.
_________________________________________________________________________
What is your disabling condition(s)?
B. Please, explain how your disability prevents you from using the Go West bus system. Be
specific. (Attach separate sheets, if necessary.)
_________________________________________________________________________
_________________________________________________________________________
C. Does your disability or health condition change form time to time in ways that affect your
ability to use Go West’s regular city bus system?
❑ No
❑ Yes (how?) ______________________________________________________
_________________________________________________________________________
D. Do you require an attendant to accompany you when you travel by public transit? (either
Go West city buses, American Red Cross, Barry’s Taxi, or Bridgeway)
❑ No
E.
❑ Yes (If yes, why?) _________________________________________________
Do you require Door to Door Assistance? (Drivers may provide assistance from your door
to the vehicle depending on the level of help you require).
❑ Yes
❑ No (You will have to meet the vehicle at the curb closest to your location.)
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PART A – FOR THE APPLICANT TO COMPLETE
Mobility Information
F.
Which of these mobility aids do you use? (If none required, skip to J.)
❑ Manual Wheelchair
❑ Cane
❑ Oxygen Tank
❑ Power Wheelchair
❑ Crutches
❑ White Cane
❑ Power Scooter
❑ Walker
❑ Other: ____________________
❑ Prosthesis
❑ Leg Brace
❑ Service Animal
G. Is your wheelchair or scooter larger than 30 inches wide by 48 inches long?
If so, you may not be able to enter or ride on an accessible paratransit vehicle with it.
❑ Yes (Width) ________
(Length) ________
❑ No, it is under these sizes.
H. Does your wheelchair or scooter (with you in it) weigh more than 600 pounds?
If so, you may not be able to enter or ride on an accessible paratransit vehicle with it.
❑ No, weight is less than 600 pounds.
❑ Yes, the combined weight is ________.
I.
Can you transfer from your wheelchair or scooter to another seat without assistance?
❑ Yes
J.
❑ No
Using your mobility aid or on your own, how many blocks can you travel? (Imagine a city
block to be approximately 500 feet in length.)
❑ 1 to 2
❑ 3 to 4
❑ 5 or more
❑ Don’t know
K. How often do you currently ride the Go West buses?
❑ Daily
❑ Weekly
❑ Monthly
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❑ Other: ________
PART A – FOR THE APPLICANT TO COMPLETE
L.
How long can you wait outside at a Go West bus stop?
❑ 5-10 minutes
❑ 10-15 minutes
❑ 15-30 minutes
❑ Other
Why? _____________________________________________________________
M. What skills do you know that enable you to ride Go West’s fixed route buses?
❑ To travel to and from bus stops
❑ To cross streets
❑ To ride all or some bus routes
❑ To read bus schedules
❑ Deal with unexpected situations
❑ Read informational signs
❑ Navigate independently
❑ Ask for, understand & follow directions
❑ Other __________________________________________________________________
N. Can you get to and from the closest Go West bus stop, from your home?
❑ Always
❑ Never
❑ Sometimes
❑ Don’t know
If never why? ______________________________________________________________
If sometimes why? __________________________________________________________
O. Have you ever been taught how to ride Go West’s buses or public buses in another city?
❑ Yes
❑ No
If yes, when? _______________________By whom? ____________________________
P.
Please, tell us anything else about your disability and how it affects your ability to use
Go West buses (attach additional sheets, if required).
_________________________________________________________________________
_________________________________________________________________________
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PART A – FOR THE APPLICANT TO COMPLETE
In order for MCPT to evaluate your request for paratransit services, it is necessary to contact your
medical professional, health care provider to confirm the information you have provided.
Please complete and sign the following authorization.
I authorize the MCPT to contact the medical professional listed below to obtain information
regarding my disability and its affect on my ability to get around on my own. I understand that all
information will be kept confidential, and only the information required to provide the services will
be disclosed to those who perform those services.
Name of Medical Professional: _____________________________________________________
Street Address: ________________________________________________________________
City: _______________________________
State: ________________
Zip: _____________
Telephone: ( ______) _________________________
Applicant’s Name: ______________________________________________________________
(Please print.)
Applicant’s Signature: ___________________________________________________________
I hereby certify that the information given in this application is correct. I understand that
falsification of information may result in denial of service.
Applicant’s Signature: ___________________________________
Date: __________________
If you are not the applicant but have completed this application on the applicant’s behalf, you must
provide the following information:
Your Name: __________________________________________________________________
Address: _____________________________________________________________________
Phone Number: ________________________________________________________________
Relationship to Applicant: ________________________________________________________
Signature: ___________________________________________
STOP
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Date: __________________
YOU HAVE COMPLETED PART-A
Take or mail Part-B of this document
to your medical professional.
The professional certification (Part-B attached)
must be filled out by an appropriate professional.
Who Can Certify:
If your disability prevents you from using the regular bus system, one of the following professionals, as
appropriate to your case, should complete Part-B. If you plan to use another professional not listed
below, you must get prior approval from the MCPT first. Please understand that MCPT may contact
your chosen professional for additional assistance.
Physician
Physical therapist
Special Education Teacher
Psychiatrist
Social worker
O&M Specialist
Psychologist
Rehabilitation specialist
Registered Nurse
Occupational therapist
Physiatrist
Other (MCPT approval)
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PART-B
FOR THE PROFESSIONAL TO COMPLETE
•
Part B must be personally completed by an Accepted Licensed Professional.
•
Please Write Legibly. Typed applications may not be accepted.
Professional: You are being asked by the applicant to provide information regarding his or her ability
to use Go West’s fixed-route transit services. MCPT (McDonough County Public Transportation) may
provide paratransit services to persons who cannot use the accessible fixed-route transit services. The
information you provide will help us evaluate the request and provide appropriate transportation
services for the applicant. All information will be kept confidential.
To qualify for paratransit services, the applicant must be unable to use Go West’s accessible fixedroute city buses due to the effects of a disability. Your certification should consider only the effects of
the applicants’ disability that prevents them from riding Go West buses.
Please note this does not include persons who find it uncomfortable or difficult to ride the bus
or get to and from the bus stop.
Go West buses are 100% accessible for individuals with disabilities. Go West buses are
equipped with . . .
•
Low floor entrances, no steps to climb when boarding or exiting the bus.
•
Kneeling features that lower the bus to the same height of a curb.
•
Audio announcements to identify buses, stops, and major landmarks.
•
Interior displays with dates, times, and route numbers and destinations.
•
Exterior displays to identify buses and their destinations.
•
Designated seating for passengers with disabilities and seniors.
•
Ramps that can be deployed over sidewalks for easy no-step boarding.
•
Wheelchair seating locations and wheelchair securement devices.
•
Fare boxes that accept passes or tokens instead of money.
•
Drivers, who will assist with boarding, exiting, or giving directions.
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PART B – REQUEST FOR PROFESSIONAL CERTIFICATION
Please answer ALL of the following about the functional ability of the applicant.
Name of Applicant: ____________________________________________________________
Capacity in which you know the applicant: __________________________________________
Primary Condition Causing Disability: (Please Describe)
____________________________________________________________________________
Severity:
____ Mild
____ Moderate
____ Severe
____ Profound
Secondary Condition Causing Disability: (Please Describe)
____________________________________________________________________________
Severity:
____ Mild
____ Moderate
Is the condition temporary?
1.
____ No
____ Severe
____ Profound
____ Yes (expected duration)
How does this person’s disability cause a functional limitation(s) that prevents his or her
ability to ride the city bus?
_________________________________________________________________________
_________________________________________________________________________
2.
If the person’s ability to get around on his/her own varies in degree at different times, please
explain. Please be specific.
_________________________________________________________________________
_________________________________________________________________________
3.
Assuming the length of a city block is 500 feet, how many city blocks can this person walk
or wheel?
❑ 1 to 2
4.
❑ 3 to 4
❑ 5 or more
❑ Other: _____________
What is this person’s ability to deal with unexpected situations one may encounter when
riding the city bus?
_________________________________________________________________________
_________________________________________________________________________
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PART B – REQUEST FOR PROFESSIONAL CERTIFICATION
5.
What is this person’s ability to recognize their destination(s) and leave the bus?
________________________________________________________________________
________________________________________________________________________
6.
What is this person’s ability to understand directions needed to ride the bus?
________________________________________________________________________
________________________________________________________________________
7.
Does this applicant require the assistance of a competent aid to travel with him or her?
❑ *Yes (always)
❑ Yes (sometimes)
❑ No
If yes, why? ______________________________________________________________
*(If “Yes Always,” then you are requiring this applicant to travel with an aid at all times and
requiring that MCPT must not schedule independent trips for this applicant. Acquiring and
paying for an aid is the responsibility of the applicant, not MCPT.
8.
Can this person cross streets at pedestrian cross walks without assistance?
❑ Yes
❑ No (If no, why?) ______________________________________________
_______________________________________________________________________
9.
Could this person benefit from Travel Training (learning how to ride the bus)?
❑ No (If no, why?) ________________________________________________________
❑ Yes (choose type of training below)
❑ Destination Training:
One-to-one instruction on how to ride the city bus to and from specific destinations.
❑ General Training:
Applicants learn how to read bus schedules and navigate Go West’s fixed bus routes.
❑ Mobility Practice:
Applicants practice boarding and exiting Go West buses.
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PART B – REQUEST FOR PROFESSIONAL CERTIFICATION
Is (are) there any other effect(s) of the applicant’s disability that MCPT should be aware of? If
so, please provide the information here. Please print (attach additional sheets, if required).
____________________________________________________________________________
____________________________________________________________________________
I have reviewed the information in this section (Part-B) and hereby certify that it is true and
correct to the best of my knowledge. I understand that knowingly providing false information on
this application to obtain, aid, or facilitate another in obtaining complementary paratransit
service violates United States Code Title 18. Penalties are fines and imprisonment.
Print Name and Title: ___________________________________________________________
Signature: ______________________________________
Clinic/Agency: _______________________________
Address: _______________________________
Date: ______________________
Phone: ________________________
City: ________________
Zip: ________
Professional License, Registration or Certification #: _________________________________
Completion of this application by any other professional will not be accepted without prior
authorization of MCPT.
Profession (check one):
❑ Physician
❑ Physical therapist
❑ Special Education Teacher
❑ Psychiatrist
❑ Social worker
❑ O&M Specialist
❑ Psychologist
❑ Rehabilitation specialist
❑ Registered Nurse
❑ Physiatrist
❑ Occupational therapist
❑ Other (MCPT approval)
Please Return Completed Applications to . . .
MCPT Paratransit Applications
1 University Circle
Disability Support Services
Seal Hall
Macomb, IL 61455
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